da Vinci Radical Prostatectomy
A radical prostatectomy is the total removal of the prostate and seminal vesicles. Ideal candidates for radical prostatectomy are healthy men with a life expectancy of greater than 10 years, Stage T1 or T2, and any Gleason score.
The Gleason Score is a scale assigned to prostate cancer
based on its microscopic appearance. Following a biopsy, the pathologist assigns the cancer a Gleason Score, from 2-10, depending on how aggressive it appears under the microscope. The Gleason Score (or Gleason Grade) is a measure of biologic aggressiveness, or how likely is it to spread and become incurable. Gleason Scores 2-6 are all lumped together as the slowest growing types, and carry the best prognosis. Gleason Score 7 is more aggressive, and Gleason Score 8-10 are considered the fastest growing types, and the most dangerous.
If the disease is detected at early stages and if men are sexually active, then a Nerve Sparing Radical Prostatectomy can be performed where the nerves responsible for erections are preserved. For patients with Gleason score of 7 or higher, or PSA greater than 10, usually the lymph nodes draining the prostate are also removed (pelvic lymphadenectomy) to make sure there has been no spread of the cancer to the lymph nodes.
Advantages of a total prostatectomy
In a total prostatectomy the surgeon removes the whole gland for pathologic evaluation, ensuring that cancer cannot recur inside the prostate, which is a risk with alternative treatments. Once the entire prostate is out, the pathologist examines the prostate under the microscope to determine if the cancer is totally confined to the prostate, or has migrated elsewhere.
Additional treatment can always be given, such as radiation therapy or hormones, based on the pathologic findings. Also, follow-up is relatively easy after a radical prostatectomy. Monitoring for recurrence of the cancer is done with the PSA blood test, which should be at undetectable levels.
A radical prostatectomy can be performed through an open incision or laparoscopically utilizing the da Vinci robot. The open radical prostatectomy has been developed and modified through the past 30 years, and has passed the test of time.
The cancer control rate is well established, due to almost thirty years of data with current techniques. An open radical retropubic prostatectomy involves an incision from the navel to the pubic bone, mild to moderate pain, two or three nights in the hospital, 10 to 14 days of catheter time, and six to eight weeks to heal and resume normal activity. There is slow recovery of bladder control and slow return of erectile function.
da Vinci Robotic Radical Prostatectomy
The da Vinci Robotic radical prostatectomy is now the most frequent type of surgery performed by the physicians at Pacific Urology for the treatment of prostate cancer.
The first robotic-assisted laparoscopic radical prostatectomy was performed at John Muir Concord Campus in 2002, and Pacific Urology physicians have performed more than 500. The da Vinci robotic radical prostatectomy has essentially replaced more traditional open surgery for 99 percent of Pacific Urology patients.
Robotic surgery attempts to mimic open surgery but by a less invasive method. This results in a faster recuperation, shorter catheterization times, more rapid return of good bladder control, more rapid return of normal sexual function, and more rapid return to normal activities.
Robotic laparoscopic surgery enables the surgeon to perform complex procedures through very small openings in the skin. This means much less pain after the procedure, smaller scars for a better cosmetic appearance, less blood loss, shorter hospital stays.
While the post-operative benefits are evident, long-term data on cancer control rates is lacking, as the technique is too new to have ten or fifteen years of data, as is the case for open radical prostatectomy.
However, most urologists who are performing the robotic radical prostatectomy feel confident that the long term data will eventually show no difference between to open and robotic techniques. Intermediate endpoints, such as PSA recurrence rates and "Positive Surgical Margins" show no difference between the two techniques.
Frequently asked questions about robotic surgery
How is robotic surgery different? Is it better?
The da Vinci approach to radical prostectomies is generally considered an advancement over standard laparoscopic surgery, which involves placing a telescope inside the body and placing small instruments through hollow tubes called ports. In this kind of surgery, the surgeon watches the instruments on a TV monitor and performs the surgery watching the monitor.
However, in laparoscopic surgery, the instruments have limited range of motion and limited degrees of freedom because there are no mechanical wrists, as there are in robotic surgery. Additionally, the operation is performed in two dimensions, in contrast to three dimensions in da Vinci surgery.
Standard laparoscopic surgery is quite adequate for many procedures which do not require delicate reconstruction – an example is gall bladder removal. For more demanding surgeries, robotic laparoscopic surgery with the da Vinci-S Robot is a completely different experience. Here the surgeon places a 3-D telescope through a small incision (10 millimeters. or a little less than a half-inch) and inserts various robotic instruments.
The robotic instruments mimic the actual movements of the human hands but have even greater degrees of freedom. The surgeon sits at a console and manipulates the robotic hands with finger controls. When the surgeon looks through the console monitor, he has a perfect 3-D view, as if he were standing inside the body.
The da Vinci-S Robot enables the surgeon to perform very precise and delicate procedures, with a high definition picture, no hand tremor, and 10-power magnification.
What types of procedures are performed with the da Vinci Robot?
The da Vinci Robot is useful for any procedure which requires fine, delicate movements and reconstruction and is ideally suited for robotic laparoscopic radical prostatectomy (also known as the da Vinci prostatectomy).
Yet the Da Vinci Robot is also useful for many other urologic procedures, such as robotic pyeloplasty (repair of congenital or acquired blockage of urine), robotic radical nephrectomy (removal of entire kidney for kidney cancer), and robotic partial nephrectomy (partial removal of the kidney).
Other uses in female patients include Robotic vaginal sacropexy (repair of vaginal prolapse). This is only a partial list of some of the more common uses of the da Vinci Robot.
What can I expect from a robotic radical prostatectomy?
A da Vinci Robotic Radical Prostatectomy is indicated for the treatment of low stage Prostate Cancer (Stage T1, T2, and some T3's). You will be admitted to the hospital the morning of your procedure, and most patients will spend one or two nights in the hospital.
The surgery is performed under General Anesthesia (with you asleep). When you wake up in the Recovery Room, you will have a catheter in the bladder and a drain in the abdomen, but you will have very little pain. After one or two hours in the Recovery Room, you will be moved to your hospital room.
The nurses will help you to walk around the same day as surgery, as lying in bed will predispose you to blood clots in your legs. Most patients are able to eat on the first day after surgery, although you will not usually have a bowel movement for several days. Most patients will have very little pain after the da Vinci Radical Prostatectomy and some patients never take a pain pill.
The drain is sometimes removed prior to discharge from the hospital, and sometimes you will go home with the drain still in place. You will be instructed in proper catheter care, drain care, diet and physical activity. It is okay to shower when you go home. You will be discharged to home when you are comfortable, able to eat, and can walk safely.
You will go home with the catheter in your bladder, and your urologist will advise you when to return to his office to have the catheter removed. Please drink plenty of liquids as long as the catheter is in place, to keep the urine as clear as possible. Keep the catheter well taped and secure to avoid it being inadvertently pulled out.
Your doctor may send you home with some of the following medications: pain pills, antibiotics (to keep the urine sterile until the catheter is removed), anti-inflammatory pills, stool softeners, etc.
What things should I report to my urologist after a da Vinci radical prostatectomy?
It is normal to have blood tinged urine after surgery and leakage of urine around the catheter; this is of no concern. Even small blood clots in the urine are normal.
Swelling of the penis and scrotum is common, and will resolve in one to two weeks. However, if you develop a high fever, over 101 F, or if the catheter stops draining, you should report this to your urologist immediately. Call the office number, as there is always a physician on call.
Other rare events to report would be pain or swelling of the legs or ankles, shortness of breath, chest pain, fainting, or other serious problems. If you have not had a bowel movement after four days, you should take a laxative, such as Milk of Magnesia.
What are the risks of a da Vinci radical prostatectomy?
Although the da Vinci robotic radical prostatectomy is usually very safe, there are risks associated with it. No procedure is 100 percent safe. The following is a list of more common risks. Risk of General Anesthesia:
Patients are so carefully monitored during general anesthesia that the risk of serious problems is very rare. The risk of death should be less than one in 100,000. There is always a risk of pneumonia, nausea, vomiting, etc. If you have nausea after the surgery, you will be given medicine to counteract the nausea.
Patients can aspirate stomach contents into the lungs after surgery, and this can be very serious. For this reason, you will be asked not to eat or drink for eight hours prior to surgery. Risks of the surgery itself:
The usual risks of surgery include bleeding and infection. Ordinarily, there is very little blood loss during a da Vinci Radical Prostatectomy, and the blood transfusion rate is about one percent. The risk of an infection in one of the skin puncture sites is about one percent. There are risks associated with any laparoscopic procedure, as CO2 gas is placed into the abdominal cavity. CO2 can enter the blood stream and cause a CO2 embolus, which can cause problems in getting the patient enough oxygen. This can lead to a heart attack or stroke.
Bowel injuries can occur from the robotic procedure, including damage to the small bowel, colon or rectum. If any injury occurs, and is recognized, it is fixed immediately during surgery. But sometimes such an injury becomes apparent only after surgery. Such problems have occurred, but fortunately they are quite rare.
There is a risk of blood clots in the legs and lungs after surgery. With this in mind, you will be asked to walk as soon and as much as possible after surgery, as this has been shown to prevent blood clots from forming.
There are certain risks specific to a radical prostatectomy, whether it is performed utilizing the da Vinci Robot or by the open technique. These specific risks are incontinence (involuntary leakage of urine) and impotence (inability to obtain or maintain an erection). In general, the risk of incontinence is between 5 and 10 percent, depending on the skill of the surgeon, age of the patient, history of previous prostate surgery, and individual anatomy.
When the da Vinci Robot is utilized, the urologist can perform a very precise reconnection of the urethra to the bladder. This results in shorter catheterization times and, in many cases, very rapid return of full bladder control.
The risk of impotence is variable, depending on how good your erections are prior to surgery, presence of diabetes, extent of hardening of the arteries, and whether "nerve sparing" is performed. Nerve sparing is the preservation of nerves needed for an erection. Because of the increased magnification and precision of the da Vinci robot, a urologist is often able to preserve these nerves in a most delicate manner, resulting in very rapid return of erections in many patients.
Patients who are potent prior to surgery, and patients with low Gleason grade and low-stage cancer, are good candidates for bilateral nerve sparing. When bilateral nerve sparing is performed, potency can be preserved in approximately 80 percent to 90 percent of patients. This is most gratifying to patients and surgeon alike.
It's important to remember that the skill and experience of each urologist is different. The da Vinci Robot does not perform the surgery but is merely a tool which enhances the skill of the urologist. The da Vinci Robot allows the skilled urologist to do a better job, more precisely and less invasively, than an open prostatectomy.